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STATE ID NUMBER 00000004568001 <br /> CONTAINER CONSTRUCTION <br /> [F ( <br /> ( ) 01 RUBBER LINED ( 7 02 ALKYD LINING f 1 03 EPDXY LINING ( ] 04 PHENOLIC LINING ( ) 05 GLASS LINING <br /> f ) 07 UNLINED (X) 08 UNKNOWN ( 7 09 OTHER: <br /> 7 O1 Po <br /> WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION [ ) 04 UNKNOWN (X7 05 NO <br /> ! l 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE [ ) 05 SUCTION ( 7 06 UNKNOWN [ 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 7 <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( ) 05 SENSOR INSTRUMENT Rrz�JL CK <br /> f ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE (X) 10 OTHER: TOR <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) <br /> STOPED STOPED CHEMICAL f00 NOT USE COMMERCIAL NAME) <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 7 02 ( ) 03 <br /> f ) 01 ( ) 02 ( 7 03 <br /> ( ) <br /> 01 ( ] 02 ! ) 03 <br /> ( 1 01 ( ) 02 f ) 03 <br /> f 7 01 ( ) 02 ( ) 03 <br /> ( ) 01 f l 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( 7 01 ( l 02 ( ) 03 <br /> it CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> I5 CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (X) 02 NO <br /> THIS FORM EEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> 0FI12��M.E <br /> )) PHONE W/AREA CO7DE <br /> 5&c-?a <br /> R <br /> F LOCAL AGENCY USE ONLY <br /> ADMINISTRATING ENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON <br /> L` P ONE W REA CODE <br /> T is <br /> DATE OF LAST INSPECTION IN COMPLIANCEPERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 7 01 YES ( 7 02 NO <br /> HSC04-070185 (10/18/85) <br /> PAGE 2 <br />